Catamenial haemothorax-A rare cause of pleural effusion

Abstract

Common causes of haemorrhagic pleural effusions include malignancy (primary or metastatic), tuberculosis, pulmonary embolism, collagen vascular diseases, trauma and iatrogenic causes. Clinical history along with pathologic, microbiologic and biochemical evaluation of pleural fluid confirms the diagnosis in most cases. However, if there is recurrent haemorrhagic effusion without corroborative history or mass lesion in lung, or evidence of microorganisms, then we should think of uncommon causes. Catamenial haemothorax (CHt) is a rare cause of haemorrhagic pleural effusion, which recurs during each menstrual cycle. This is a manifestation of thoracic endometriosis syndrome (TES) caused by ectopic endometrial tissue in the thoracic cavity in women of child-bearing age. This extremely rare condition is difficult to diagnose, unless direct correlation with the menstrual cycle is established. TES consists of pleural forms such as catamenial pneumothorax, non-catamenial endometriosis-related pneumothorax and haemothorax; and parenchymal forms such as catamenial haemoptysis and lung nodules. Here we report a case of CHt in a 43-year-old female whose diagnosis was established by thoracoscopic pleural biopsy.

Keywords: Catamenial; endometriosis; haemothorax.

Figure 1

(a) Chest X-ray PA view showing moderate pleural effusion on the right side. (b) Aspirated pleural fluid which is hemorrhagic shows plenty of RBCs

Figure 2

(a) CECT thorax showing moderate pleural effusion on the right side. There are no pleural or parenchymal nodules. (b) CECT abdomen showing left ovarian cyst (red arrow) and a large adnexal mass close to the uterus and left ovarian cyst

Figure 3

(a) showing thoracoscopic view of right diaphragmatic pleura. Chocolate-coloured cysts are seen on the background of hemorrhagic pleural effusion. (b) showing brownish-black nodular lesion on the pleural surface referred to as ‘gunshot lesions’

Figure 4

(a) Low power view and (b) high power view of biopsy showed foci of endometrial glands lined by pseudostratified columnar epithelium with surrounding cellular endometrial stroma